Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement

OBJECTIVES

Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.

METHODS

GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research.

RESULTS

Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research.

CONCLUSIONS

ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.

Emergency Orthogeriatrics: Concepts and Therapeutic Considerations for the Geriatric Patient

Appropriate recognition of the physiologic, psychological, and clinical differences among geriatric patients, with respect to orthopedic injury and disease, is paramount for all emergency medicine providers to ensure they are providing high-value care for this vulnerable population.

White Paper-Geriatric Emergency Medicine Education: Current State, Challenges, and Recommendations to Enhance the Emergency Care of Older Adults

Older adults account for 25% of all emergency department (ED) patient encounters. One in five Americans will be 65 or older by 2030. In response to this need, geriatric emergency medicine (GEM) has developed into a robust area of academic and clinical interest, with extensive evidence-based research and guidelines, including clear undergraduate and postgraduate GEM competencies. Despite these developments, GEM content remains underrepresented in curricula and licensing examinations. The complex reasons for these deficits include a perception that care of older adults is not a core emergency medicine (EM) competency, a disjunction between traditional definitions of expertise and the GEM perspective, and lack of curricular capacity. This White Paper, prepared on behalf of the Academy of Geriatric Emergency Medicine, describes the state of GEM education, identifies the challenges it faces, and reviews innovations, including research presented at the 2018 Society for Academic Emergency Medicine (SAEM) Annual Scientific Meeting. The authors propose a number of recommendations. These include recognizing GEM as a core educational priority in EM, enhancing academic support for GEM clinician-educators, using social learning and practical problem solving to teach GEM concepts, emphasizing a whole-person multisystem approach to care of older adults, and identifying ageist attitudes as a hurdle to safe and effective GEM care.

Older Adult Emergency Department Pain Management Strategies

Older adults frequently present to the emergency department (ED) with pain, which is often underrecognized and undertreated. There is high variability of pain management and prescribing practices by ED providers. This article focuses on treatment of older adults in the ED who present with pain and addresses special considerations for this population. Social supports and follow-up must be considered in discharge treatment recommendations.

Communication Strategies for Better Care of Older Individuals in the Emergency Department

The need for teamwork and communication among emergency department staff is central to excellent health care and of particular importance for the complex older adult population. Communication can decrease error, enhance safety, and improve throughput. Communication strategies both among multiple health care professionals, and between professionals and family and/or patients can improve care for older adults in the unique emergency department environment.

Shared Decision Making to Improve the Emergency Care of Older Adults: A Research Agenda

Older emergency department patients have high rates of serious illness and injury, are at high risk for side effects and adverse events from treatments and diagnostic tests, and in many cases, have nuanced goals of care in which pursuing the most aggressive approach is not desired. Although some forms of shared decision making (SDM) are commonly practiced by emergency physicians caring for older adults, broader use of SDM in this setting is limited by a lack of knowledge of the types of patients and conditions for which SDM is most helpful and the approaches and tools that can best facilitate this process. We describe a research agenda to generate new knowledge to optimize the use of SDM during the emergency care of older adults.

Improving Pain Relief in Elder Patients (I-PREP): An Emergency Department Education and Quality Intervention

OBJECTIVES

To assess the effectiveness of a novel combined education and quality improvement (QI) program for management of pain in older adults in the emergency department (ED).

DESIGN

Controlled pre/postintervention examination.

SETTING

An academic urban ED seeing 60,000 adult visits annually.

PARTICIPANTS

Individuals aged 65 and older experiencing moderate to severe pain.

INTERVENTION

Linked standardized education and continuous QI for multidisciplinary staff in an urban, academic ED from January 2012 to January 2014.

MEASUREMENTS

Pain intensity, percentage receiving and time to pain assessment and reassessment, percentage receiving and time to delivery of analgesic.

RESULTS

The percentage of participants with final pain score of 4 or less (out of 10) increased 47.5% (95% confidence interval (CI) = 41.8-53.2%). Median decrease in pain intensity improved significantly, from 0.0 to 5.0 points (P < .001). Median final pain score decreased from 7.0 to 4.0 points (P < .001). The percentage of participants with any pain improvement increased 43.7% (95% CI = 37.1-50.3%, P < .001). Pain reassessments increased significantly (from 51.9% to 82.5%, P < .001). The percentage receiving analgesics increased significantly (from 64.1% to 84.8%, P < .001). After the intervention, participants had 3.1 (95% CI = 2.1-4.4, P < .001) greater odds of receiving analgesics and 4.7 (95% CI = 3.5-6.5, P < .001) greater odds of documented pain reassessment.

CONCLUSION

The I-PREP intervention substantially improved pain management in older adults in the ED with moderate to severe musculoskeletal or abdominal pain. Significant reductions in pain intensity were achieved, the timing of pain assessments and reassessments was improved, and analgesics were delivered faster. Tightly linking education to targeted QI improved pain management of older adults in the ED.

Evaluation of Syncope in Older Adults

The older adult patient with syncope is one of the most challenging evaluations for the emergency physician. It requires clinical skill, patience, and knowledge of specific older adult issues. It demands care in the identification of necessary resources, such as medication review, and potential linkage with several multidisciplinary follow-up services. Excellent syncope care likely requires reaching out to ensure institutional resources are aligned with emergency department patient needs, thus asking emergency physicians to stretch their administrative talents. This is likely best done as preset protocols prior to individual patient encounters. Emergency physicians evaluate elders with syncope every day and should rise to the challenge to do it well.

Assessing knowledge base on geriatric competencies for emergency medicine residents

Introduction

Emergency care of older adults requires specialized knowledge of their unique physiology, atypical presentations, and care transitions. Older adults often require distinctive assessment, treatment and disposition. Emergency medicine (EM) residents should develop expertise and efficiency in geriatric care. Older adults represent over 25% of most emergency department (ED) volumes. Yet many EM residencies lack curricula or assessment tools for competent geriatric care. Fully educating residents in emergency geriatric care can demand large amounts of limited conference time. The Geriatric Emergency Medicine Competencies (GEMC) are high-impact geriatric topics developed to help residencies efficiently and effectively meet this training demand. This study examines if a 2-hour didactic intervention can significantly improve resident knowledge in 7 key domains as identified by the GEMC across multiple programs.

Methods

A validated 29-question didactic test was administered at six EM residencies before and after a GEMC-focused lecture delivered in summer and fall of 2009. We analyzed scores as individual questions and in defined topic domains using a paired student t test.

Results

A total of 301 exams were administered; 86 to PGY1, 88 to PGY2, 86 to PGY3, and 41 to PGY4 residents. The testing of didactic knowledge before and after the GEMC educational intervention had high internal reliability (87.9%). The intervention significantly improved scores in all 7 GEMC domains (improvement 13.5% to 34.6%; p<0.001). For all questions, the improvement was 23% (37.8% pre, 60.8% post; P<0.001) Graded increase in geriatric knowledge occurred by PGY year with the greatest improvement post intervention seen at the PGY 3 level (PGY1 19.1% versus PGY3 27.1%).

Conclusion

A brief GEMC intervention had a significant impact on EM resident knowledge of critical geriatric topics. Lectures based on the GEMC can be a high-yield tool to enhance resident knowledge of geriatric emergency care. Formal GEMC curriculum should be considered in training EM residents for the demands of an aging population.

Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis

OBJECTIVES

A significant proportion of geriatric patients experience suboptimal outcomes following episodes of emergency department (ED) care. Risk stratification screening instruments exist to distinguish vulnerable subsets, but their prognostic accuracy varies. This systematic review quantifies the prognostic accuracy of individual risk factors and ED-validated screening instruments to distinguish patients more or less likely to experience short-term adverse outcomes like unanticipated ED returns, hospital readmissions, functional decline, or death.

METHODS

A medical librarian and two emergency physicians conducted a medical literature search of PubMed, EMBASE, SCOPUS, CENTRAL, and ClinicalTrials.gov using numerous combinations of search terms, including emergency medical services, risk stratification, geriatric, and multiple related MeSH terms in hundreds of combinations. Two authors hand-searched relevant specialty society research abstracts. Two physicians independently reviewed all abstracts and used the revised Quality Assessment of Diagnostic Accuracy Studies instrument to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for predictors of adverse outcomes at 1 to 12 months after the ED encounters. A hypothetical test-treatment threshold analysis was constructed based on the meta-analytic summary estimate of prognostic accuracy for one outcome.

RESULTS

A total of 7,940 unique citations were identified yielding 34 studies for inclusion in this systematic review. Studies were significantly heterogeneous in terms of country, outcomes assessed, and the timing of post-ED outcome assessments. All studies occurred in ED settings and none used published clinical decision rule derivation methodology. Individual risk factors assessed included dementia, delirium, age, dependency, malnutrition, pressure sore risk, and self-rated health. None of these risk factors significantly increased the risk of adverse outcome (LR+ range = 0.78 to 2.84). The absence of dependency reduces the risk of 1-year mortality (LR- = 0.27) and nursing home placement (LR- = 0.27). Five constructs of frailty were evaluated, but none increased or decreased the risk of adverse outcome. Three instruments were evaluated in the meta-analysis: Identification of Seniors at Risk, Triage Risk Screening Tool, and Variables Indicative of Placement Risk. None of these instruments significantly increased (LR+ range for various outcomes = 0.98 to 1.40) or decreased (LR- range = 0.53 to 1.11) the risk of adverse outcomes. The test threshold for 3-month functional decline based on the most accurate instrument was 42%, and the treatment threshold was 61%.

CONCLUSIONS

Risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post-ED adverse outcomes. Future research to derive and validate feasible ED instruments to distinguish vulnerable elders should employ published decision instrument methods and examine the contributions of alternative variables, such as health literacy and dementia, which often remain clinically occult.

Multidimensional attitudes of emergency medicine residents toward older adults

Introduction

The demands of our rapidly expanding older population strain many emergency departments (EDs), and older patients experience disproportionately high adverse health outcomes. Trainee attitude is key in improving care for older adults. There is negligible knowledge of baseline emergency medicine (EM) resident attitudes regarding elder patients. Awareness of baseline attitudes can serve to better structure training for improved care of older adults. The objective of the study is to identify baseline EM resident attitudes toward older adults using a validated attitude scale and multidimensional analysis.

Methods

Six EM residencies participated in a voluntary anonymous survey delivered in summer and fall 2009. We used factor analysis using the principal components method and Varimax rotation, to analyze attitude interdependence, translating the 21 survey questions into 6 independent dimensions. We adapted this survey from a validated instrument by the addition of 7 EM-specific questions to measures attitudes relevant to emergency care of elders and the training of EM residents in the geriatric competencies. Scoring was performed on a 5-point Likert scale. We compared factor scores using student t and ANOVA.

Results

173 EM residents participated showing an overall positive attitude toward older adults, with a factor score of 3.79 (3.0 being a neutral score). Attitudes trended to more negative in successive post-graduate year (PGY) levels.

Conclusion

EM residents demonstrate an overall positive attitude towards the care of older adults. We noted a longitudinal hardening of attitude in social values, which are more negative in successive PGY-year levels.

A profile of acute care in an aging America: snowball sample identification and characterization of United States geriatric emergency departments in 2013

BACKGROUND

The aging of America poses a challenge to emergency departments (EDs). Studies show that elderly patients have poor outcomes despite increased testing, prolonged periods of observation, and higher admission rates. In response, emergency medicine (EM) leaders have implemented strategies for improved ED elder care, enhancing expertise, equipment, policies, and protocols. One example is the development of geriatric EDs gaining in popularity nationwide. To the authors' knowledge, this is the first research to systematically identify and qualitatively characterize the existence, locations, and features of geriatric EDs across the United States.

OBJECTIVES

The primary objective was to determine the number, distribution, and characteristics of geriatric EDs in the United States in 2013.

METHODS

This was a survey with potential respondents identified via a snowball sampling of known geriatric EDs, EM professional organizations' geriatric interest groups, and a structured search of the Internet using multiple search engines. Sites were contacted by telephone, and those confirming geriatric EDs presence received the survey via e-mail. Category questions included date of opening, location, volumes, staffing, physical plant changes, screening tools, policies, and protocols. Categories were reported based on general interest to those seeking to understand components of a geriatric ED.

RESULTS

Thirty-six hospitals confirmed geriatric ED existence and received surveys. Thirty (83%) responded to the survey and confirmed presence or plans for geriatric EDs: 24 (80%) had existing geriatric EDs, and six (20%) were planning to open geriatric EDs by 2014. The majority of geriatric EDs are located in the Midwest (46%) and Northeast (30%) regions of the United States. Eighty percent serve from 5,000 to 20,000 elder patients annually. Seventy percent of geriatric EDs are attached to the main ED, and 66% have from one to 10 geriatric beds. Physical plant changes include modifications to beds (96%), lighting (90%), flooring (83%), visual aids (73%), and sound level (70%). Seventy-seven percent have staff overlapping with the nongeriatric portion of their ED, and 80% require geriatric staff didactics. Sixty-seven percent of geriatric EDs report discharge planning for geriatric ED patients, and 90% of geriatric EDs had direct follow-up through patient callbacks.

CONCLUSIONS

The snowball sample identification of U.S. geriatric EDs resulted in 30 confirmed respondents. There is significant variation in the components constituting a geriatric ED. The United States should consider external validation of self-identified geriatric EDs to standardize the quality and type of care patients can expect from an institution with an identified geriatric ED.

Development of geriatric competencies for emergency medicine residents using an expert consensus process

BACKGROUND

The emergency department (ED) visit rate for older patients exceeds that of all age groups other than infants. The aging population will increase elder ED patient utilization to 35% to 60% of all visits. Older patients can have complex clinical presentations and be resource-intensive. Evidence indicates that emergency physicians fail to provide consistent high-quality care for elder ED patients, resulting in poor clinical outcomes.

OBJECTIVES

The objective was to develop a consensus document, "Geriatric Competencies for Emergency Medicine Residents," by identified experts. This is a minimum set of behaviorally based performance standards that all residents should be able to demonstrate by completion of their residency training.

METHODS

This consensus-based process utilized an inductive, qualitative, multiphase method to determine the minimum geriatric competencies needed by emergency medicine (EM) residents. Assessments of face validity and reliability were used throughout the project.

RESULTS

In Phase I, participants (n=363) identified 12 domains and 300 potential competencies. In Phase II, an expert panel (n=24) clustered the Phase I responses, resulting in eight domains and 72 competencies. In Phase III, the expert panel reduced the competencies to 26. In Phase IV, analysis of face validity and reliability yielded a 100% consensus for eight domains and 26 competencies. The domains identified were atypical presentation of disease; trauma, including falls; cognitive and behavioral disorders; emergent intervention modifications; medication management; transitions of care; pain management and palliative care; and effect of comorbid conditions.

CONCLUSIONS

The Geriatric Competencies for EM Residents is a consensus document that can form the basis for EM residency curricula and assessment to meet the demands of our aging population.

The use of head computed tomography in elderly patients sustaining minor head trauma

The study objectives were to ascertain historical and clinical criteria differentiating intracranial injury (ICI) in elderly patients with minor head trauma (MHT), and determine applicability of current head computed tomography (CT) scan indications in this population. A 12-month retrospective chart review was performed at a community teaching hospital with 34,000 annual Emergency Department (ED) visits. Included were patients > or = 65 years old sustaining MHT with a Glasgow Coma Scale (GCS) score of 13-15 who had a CT scan performed during their hospital stay. Data included: injury mechanism, symptoms, signs, GCS, anticoagulation use or studies, presence of alcohol or drug, CT scan result, diagnosis, and outcome and intervention(s). There were 133 patients, with 19 (14.3%) suffering ICI. Four ICI patients required neurosurgical intervention. The mean age was 80.4 years and 66% were female. Four of 19 ICI patients (21%) had a GCS of 15, no neurologic symptoms, alcohol use or anticoagulation. Only 1 of 13 signs and symptoms correlated with ICI. In this study, no useful clinical predictors of intracranial injury in elderly patients with MHT were found. Current protocols based on clinical findings may miss 30% of elderly ICI patients. Head CT scan is recommended on all elderly patients with MHT.

Medical emergencies at a major international airport: in-flight symptoms and ground-based follow-up

BACKGROUND

There is limited recent data about the treatments and outcomes of commercial airline passengers who suffer in-flight medical symptoms resulting in subsequent EMS evaluation. The study objectives are to determine incidence, post-flight treatments, outcomes, morbidity, and mortality of these in-flight medical emergencies (IFMEs).

METHODS

A 1-yr retrospective study of emergency medical service (EMS), emergency department (ED), and inpatient hospital records of IFME patients from Chicago O'Hare International Airport was completed. All commercial passengers or crew with in-flight medical symptoms who subsequently activated the EMS system on flight arrival are included in the study. The main outcome measures are: in-flight sudden deaths, post-flight mortality, hospital admission rate, ICU admission rate, ED procedures, inpatient procedures, and discharge diagnoses.

RESULTS

There were 744 IFMEs for an incidence of 21.3 per million passengers per year. The hospital admission rate was 24.5%. The ICU admission rate was 5.9%. There were five in-flight sudden deaths and six in-hospital deaths for an overall mortality rate of 0.3 per million passengers per year. Emergency stabilization procedures were required on 4.8% of patients. Cardiac emergencies accounted for 29.1% of inpatient diagnoses and 13.1% of all discharge diagnoses.

CONCLUSIONS

The incidence of in-flight medical emergencies is small but these IFMEs are potentially lethal. Although the majority of IFME patients have uneventful outcomes, there is associated morbidity and mortality. These included in-flight deaths, in-hospital deaths, and emergency procedures. Cardiac emergencies were the most common of serious EMS evaluated in-flight medical emergencies.

The rate and risk of heat-related illness in hospital emergency departments during the 1995 Chicago heat disaster

OBJECTIVES

To conduct an Emergency Department (ED)-based treated prevalence study of heat morbidity and to estimate the rate and risk of heat morbid events for all Chicago MSA EDs (N = 95; 2.7 million visits per year).

METHODS

ED patient log data were compiled from 13 randomly selected hospitals located throughout the Chicago MSA during the 2 weeks of the 1995 heat disaster and from the same 2-week period in 1994 (controls). Measurements included: age, sex, date, and time of ED service, up to three ICD-9 diagnoses, and disposition.

RESULTS

Heat morbidity for Chicago MSA hospital EDs was calculated at 4,224 (95% CI = 2964-5488) cases. ED heat morbidity increased significantly 5 days prior to the first heat-related death. In 1995, there was an increase in the estimated relative risk for the city = 3.85 and suburbs = 1.89 over the control year of 1994.

CONCLUSIONS

Real time ED-based computer automated databanks should be constructed to improve public health response to infectious or noninfectious outbreaks. Rapid area-wide M&M tabulations can be used for advancing the effectiveness of community-based prevention programs, and anticipating hospital ED resource allocation.

Multicenter study of case finding in elderly emergency department patients

OBJECTIVES

To assess the feasibility of a brief comprehensive case-finding program for detecting functional, cognitive, and social impairments among elderly ED patients and to estimate the prevalence of unknown, undetected, or untreated impairments elderly patients may have.

METHODS

A multicenter prospective study conducted at five private and public hospital EDs in five different communities across the country. Patients aged 60 years and older released to their homes during 52 randomly selected evening and weekend shifts between February 1 and April 30, 1993, were eligible for the case-finding program. They were evaluated by medical students who received special training (instructional videotape, supervised examinations, and conference calls) in the administration of a standardized 17-item protocol that included an interview and simple tests of function. The patients' physicians were notified of the screening results and were asked to return a one-month follow-up questionnaire. The physicians answered whether the presumed problem had been confirmed and whether a treatment plan for a new problem had been developed.

RESULTS

Patient acceptance of the case-finding program was good; 252 of 338 eligible patients (75%) agreed to participate, and 281 conditions were detected for 242 screened patients (96%). The most frequently reported problems were with: performing the activities of daily living (79%); vision (55%); lack of influenza vaccination (54%); home environment (49%); mental status (46%); general health (41%); falls (40%); and depression (36%). The physicians returned questionnaires for 153 patients (63%); 76 patients (50%) were evaluated at follow-up visits, during which 47 newly identified problems (62%) were confirmed and treatment plans were developed for 25 problems (53%) among 21 patients. A mean time of 17.7 +/- 10.2 minutes was required to complete the screen.

CONCLUSIONS

A brief comprehensive case-finding program for functional, cognitive, and social impairment among elderly ED patients is feasible. The screening uncovered a significant amount of morbidity among older patients visiting EDs.

Geriatric patient emergency visits. Part II: Perceptions of visits by geriatric and younger patients

OBJECTIVES

To compare group perceptions of reasons for emergency department care, ED use patterns, and the effect of illness on self-care ability for elderly and younger adult patients.

DESIGN

Patient survey.

SETTING

Six geographically distinct US hospital EDs.

PARTICIPANTS

From each site, a stratified sample (approximately 7:3) of elderly (65 years and older) and nonelderly (21 to 64 years old) control ED patients treated during the same time period was contacted.

METHODS

Three hundred ninety-nine elderly patients and 172 adult controls were interviewed using a structured survey instrument. Groups were compared using chi 2 analysis and the Mann-Whitney U test.

RESULTS

Both the elderly and the control patients (49% versus 38%) commonly stated that the most important reason for coming to the ED was because they were "too sick to wait for an office visit." Of patients with a regular physician, both groups often were referred to the ED by their primary care provider (35% versus 26%). While the elderly had more visits to their primary care provider (3.3 versus 2.9 visits; P less than .00001), there was no difference in the number of ED visits (1.5 versus 1.6 visits) during the preceding six months. Of those released from the ED, more elderly noted deterioration in their ability to care for themselves as a result of their illness (21% versus 11%; P less than .03).

CONCLUSION

The elderly use the ED for reasons similar to those for younger adults. Often they feel too ill to wait for an office visit or are referred in by their primary care provider. Elderly patients more commonly have difficulty with self care after release home, and emergency physicians must plan accordingly.

Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients

OBJECTIVES

To describe emergency department use by the elderly, to define problems associated with emergency care of the elderly, and to compare these results with those for younger adult patients.

DESIGN

Retrospective, controlled chart review.

SETTING

Six geographically distinct US hospital EDs.

PARTICIPANTS

From each site, a stratified sample (approximately 7:3) of elderly (65 years or older) and nonelderly (21 to 64 years old) control patients treated during the same time period was used.

METHODS

Standardized review of ED records and billing charges. Comparisons of elderly and control patient groups using chi 2 analysis and Mann-Whitney U test (alpha = 0.05).

RESULTS

Four hundred eighteen elderly patients and 175 nonelderly controls were entered into the study. The elderly were more likely to arrive by ambulance (35% versus 11%; P less than .00001). More elderly than controls presented with conditions of either high or intermediate urgency (78% versus 61%; P less than .0003). The elderly more frequently presented with comorbid diseases (94% versus 63%; P less than .00001). Other findings for the elderly included a longer mean stay in the ED (185 versus 155 minutes; P less than .003), higher laboratory (78% versus 53%; P less than .00001) and radiology (77% versus 52%; P less than .00001) test rates, higher mean overall care charges ($471 versus $344; P less than .00001), and an admission rate (47% versus 19%; P less than .00001) twice that of younger adults.

CONCLUSION

Resource use and charges associated with emergency care are higher for the elderly than for younger patients. Increases in emergency resources and personnel or improvement in efficiency will be needed to maintain emergency care at present levels as the US population continues to grow and age.